07867 (PLBG)Building
Address 51.615 Ave. Herrera
Owner
Nick Mini+ck
Mailing
Address 01341a Rosa Dr.
City IZip Tel.
Contractor
Address
U315 Kieley Read
City . _ Zip Tela
State Lic. City
& Classif. Lic. #
4
u
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
Arch., Engr.; I
Designer
Address Tel.
City I Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
000) of Division 3 of the Business and Professions Cod and my license is in full force and
ff ct.
'r GNA'FURE'� "-�"�'" \.. DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec.. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is 'exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wagez as their sole compensation, will
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and
Professions Code:The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or Improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
❑ I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed it the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of C hfor
VDate t Owner �+ F se " t_ �
!%(40T10E0 AP�PL�CANT: I!, alvei-rmakm fhls Certificate of Exemption - you !should become
subject to the Workers` Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances andstate laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-.
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, Slate, Zip
BUILDING: TYPE CONST
Number . iMI143.M7
No. 078£7
OCC: GRP.
Legal Description
Project Description jaSta1l sAnt4c map _t=
T
Sq. Ft.
Size
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation.
a
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
45.00
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
- nnr.4 A5 +Q0,4A AVr_nr . ^n ,
REMARKS
id� 1'�TC
Xis AS.TAV 1� 45.00 �
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
5/e/90
Issued by: Date Permit
Validated by:
q
Validation:
T
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. @ $
UNITS
SLAB GRADE
2ND FL. SD. FT. @
BONDING
YARD SPKLR SYSTEM
STORAGE TANK
MOBILEHOME SVC.
BAR SINK
FOR. SO. FT. @
DUCT WORK
ROCK STORAGE
GAR. SQ. FT. @
POWER OUTLET
ROOF DRAINS
HEATING (FINAL)
OTHER APPJEQUIP.
DRAINAGE PIPING
CAR P. SQ. FT. @
TEMP. POLE
WALL SQ. FT. @
GROUT
DRINKING FOUNTAIN,
SO FT @
FINAL INSP.
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER SYSTEM
WATER PIPING
NOTE: Not to be used as property tax valuation
=$
FLOOR DRAIN
MECHANICAL FEES
FINAL INSP.
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
VENTILATION
LAUNDRY TRAY
AIR HANDLING UNIT CFM
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET'
COMPRESSOR HP
POLE, TEM/PERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. @ c
BATH TUB
SO. FT. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID @ 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR @ V4c
HOUSE SEWER
INSULATIONISOUND
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS 3
�O 6�ER R SEPS'IC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
1
0
1 O
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL
COUNTY OF RIVERSIDE DEPARTMENT.OF HEALTH +P"°'IINo.
ENVIRONMENTAL SERVICES DIVISION 773- /33 - 007--7
PERMIT APPLICATION FOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM
Applicant: Submit this form with four copies of a scaled plot plan (1-20 scale) drawn to County speculations as indicated on the attached check list
T�f�I� non-rQ dabte�filirig fee (see below) is required when the application is submitted. Check must be made payable to the County of
Rtti��verside.ARof proval this application shall remain valid for a period not to exceed one year from date of approval.
`$
VERIFY ITEMS9AECTION}A FROM BUILDING & SAFETY APPLICATION BUILDING DEPARTMENT APPLICATION LOG #
t. Cont or, Contact Person
Phone
Address & Firm
Owner
Phone oP/ 3
Mailing Address J
City
State
Zip
Job Property Address
Legal Description Prop. (PM, Tract, Lot) 07'/8
/
cll -
.S. �n
.S/ G /t- a -J -t -.-r r
n. Pn J.r c a..J."*
Lot Size �
�X/00 r
� to. Agency
Use of Pia it P/P, CU etc. 44'-1 a -t�w'r-• n
Other
0
�� 7'
Dwelli
Data
Signature of Applicant
Signature
CATEGORY: REV CODE 19E
CATEGORY: REV CODE FEE
p� SUBSURFACE DISPOSAL 1238(:$f57-00
❑ SITE EVALUATION UPON REQUEST 7349 $ 43.00
p MULTIPLE PARCELS WITHIN SAME
(NO PLOT PLAN)
LAND DIVISION
❑ SEWER/SEPTIC VERIFICATION 7348 $ 17.00
a. 1 at 4 Parcels (Each) 1238 $ 57.00
(Less than 1 year)
b. Each Parcel after 4 7344 $ 24.00
❑ PRELIMINARY ELECTIVE 7352 $ 23.00
❑ Rereview (2nd review same parcel) 7344 $ 24.00
EVALUATION (Attach DOH SAN 53)
❑ Site Evaluation in Conjunction with
❑ HOLDING TANK 7351 $ 47.00
Critical Area 7348 $111.00
❑ ALTERNATIVE/EXPERIMENTAL 7345 $222.00
O Site Evaluation Lot Less than
SYSTEM
10,000 Sq. Ft. 7347 $ 87.00
11 ITIy//L�DApTE p
Holding Tank Agreements Completed ❑ Yes No f�. EP O • / 0
Certification of Existing S.D. System Required ❑ Yes 17 No
WQCB Clearance required. (Attach Form ❑ Yes Q No
DOH SAN 007, Santa Ana Region Only)
Sd18 Percolation Report Required. ❑ Yes No
Special Feasibility Boring Report Required. ❑ Yes
Detailed Contour.Plot Plans Required (1 to 5 R interval) ❑ Yes - NQ�
Other ❑ Yes No
Staff Specialist Lot Inspection Required ; ❑ Yes [7 No
Lot Inspection Date
Solis boring report by Project 4f Date
p c7
/ - 5
Solis Map Page Soil Type Approved by Dale
No. of Systema
TA of System(s)
❑ Holding Tank ❑
No Dwelling tinker )
Bedrooms,�ix
(1) Septic Tank
Soil Rate
Greaee/Send
�—
ng
El Now epmoerrwnt
rinks•
Eyi5�,13Bcj7AeI1Gl.Fk�r
G Intcp
/D�i7lG�
02.3
a., Gel
Leach LIne Sq. FL
Sidewall allowance
Ins'te l6 '_ ne(s) tt. long ft wide with
®poach Bed sq. R
trench ane
ft rock/
per running R d
min. irrcFres raClr+belpw�`ines or
a'
Leechlines/bed special design for slope:
fic:ableInlet
(3) Pit Diameter
t
No. Pita
Ph Below
(BI)
Seepage Pit Total Depth
(TD) �� x
O(�ier
Max. Alk>Ie Depth
NIA � Overburden factor
6
aLLI
J
No. 2 System
REMARKS: �/D cel �.P.�..�1.1"�F.2�^ ! � L„Q!/Y��.Z��_•..,
ffff..0000�
/A. A
/_
This application is APPROVED E 41150 for the category checked in SECTION B above, regarding the design of a subsurface disposal system as indicated
on the accompanied p t plan, using the requirements set forth in SECTION C above. A building permit is necessary for the installation of the .
above -designed system. No Construction is permitted in the required reserved 10096 expansion area.
aSeptic tank and sewer lines must be 50' minimum from any wellscV/0 7r- -a -
Leach lines must be 100' minimum from any wells, including expans ar
3.) Seepage pits must be 50' minimum from any wells, including expansion areal/0
�/ p
�"'"t?'��'Ltit w
� �' v / 0
lam- =., 1 s"
Signature of Health Offl Dia
Alsess
ti
.� .9D
RECEIPT NO. Issued By i` Date 0
DISTRICT: ❑ Riverside, &-"tndio' ❑ Hemet ❑ Perris ❑ Rancho Calif. ❑ Blythe
DOH -SAN -122 (Rev. 3i90) DISTRIBUTION: . WHITE - Office fib
YELLOW Applicant PINK - Bidg. Dept GOLDENROD - Plans/Records
i'r-0
�• oT ► 8 k- 1- nc-K Sa.
HENDRICKSON CONSTRUCTION, INC.
General Engineering Contractor • Underground Specialists
,. (r.-•..�� � < < � fir/
(T -o 9F QBAn►Dv�/f� vU �l re c. �- —�
Sca%o( Y '\ �' \ L�O
pur of Cc' AVS to
Clw OF _ _ o 0 0 �`o �tyP1
LA U 1 N ` -rt-r,3 t \�-'l o 6"aw
PLANNING & DEVELOPMENT DEPARTMENT ,
BUILDING DIVISIONCONDITIONALLY
o
N2.w Lo
ACCEPTED FOR CONST UCS P 4-5-z ? --�-
SUBJECT TO INSTALLATION AS PER
V AND ALL APPLICABLE CODES
DATE S 4 0 BY����,
- r 1 -.L.
Post Office Box U • Cathedral City, CA 92234 a (619) 328-1747 .
License #256184-A
.Er fN
RIVE RGIDE COUMIT DEPAM WENT OF PUB UC HEALTH
D"ION 07'84WROMUMM KEALM
Fmd ESWMnurd
TraDw Palk 035.-SDV.' Tark
NOW, AM. HM, Ssf. R-ol Lm -,h trfi®
6-mmm '5xlsT- ( pit
cm.-f3rdl-I suiwma C-OPA-ftliCA to
xfib
or -s a in&&&Wtraw
;V16'... 4—j
W" i'cl wx3m&. (c vw—;D
Cof"Le.
AA seyl-ar d' F. W44W"
Any cu ..,z ndl- fw r"
�Apprtval t? s—
This is to ca; ft thit tt,o C4'wTj',j a';-'qSIU'w;d 01 Pu*A-. NWAU11 dz;i-rcxu for axxoqw. wrIeruc'%'4;-JI-
installation the Item(s) &-vdKW 7 9 ale
Date —
MAWAN W M EWAN&ON AFM& M. Fr-QU ANY VrULL
FMN ANV MW UM OR VIATM UAft--/Lc
and
Sort,,
.c [hir. n."anst ba, 50 ft.
fm jr.c';udjr.jS expambn areas.
LI
mpap pft muxt be 150 ft. IR9111ifflUM ftW
OW weft
-`AP;g4!V--I Of maro pivas by L-A iuparmes: of 1--mbu%
:71� 7C
�111'. t ff. - Kealth of R-iv';rzide'County does P.44 relk" the Engbi,
JAV
e6r,ov Azebitect of the rczqons for 0o,ftkam.
LID FOR ONE (1) YEAR. mty.
s VA tax or ArtlAtestmi &Mize
FROM DATE Of AMOVAL